MEDICARE: MELMAR LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician	01043881A	IN

General Provider Information

NPI Number	:	1356544308
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MELMAR LLC

Provider Business Mailing Address
First Line	:	2410 N GLENDALE DR
Second Line	:	SUITE C
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-8908
Country	:	US
Telephone Number	:	260-432-7654
Fax Number	:	260-432-7709

Provider Business Practice Location Address
First Line	:	2410 N GLENDALE DR
Second Line	:	SUITE C
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-8908
Country	:	US
Telephone Number	:	260-432-7654
Fax Number	:	260-432-7709

Authorized Official
Title or Position	:	COO
Name	:	DR. MARCUS A JIMENEZ
Credential	:	M.D.
Telephone Number	:	260-432-7654

Provider Enumeration Date	:	06/07/2007
Last Update Date	:	08/22/2020

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Directions to “MELMAR LLC ” Practice Location

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